Structured Programmes - Dealing with the Agitated Patient
One of the most challenging aspects of brain injury rehabilitation is managing the agitated patient in the early stages of recovery following injury. The acutely confused patient with low stimulation and frustration tolerance, poor attention and memory function is detached from present reality and exhibits behaviours which present a barrier to rehabilitation attempts.
The Inpatient programme of the Westmead Brain Injury Rehabilitation Service has introduced "structured programmes" into its service as a tool for effectively managing the agitated patient. Structured programmes acknowledge the cognitive limitations of patients in the early stages of recovery and manages these limitations to effectively control the behavioural consequences which are agitation and aggression.
A structured programme is a patient timetable which ensures a patient receives a consistent and balanced routine of activity and rest throughout the day. The nature and duration of activities are controlled according to the patient's stimulation tolerance levels. Activities are usually limited to basic functional tasks and routines.
The Ranchos Los Amigos Cognitive Functioning Scale (RLACFS) is used to classify patients according to their stage of recovery following injury. Patients assessed as being in RLACFS Stages 4 and 5 are allocated a structured programme due to their agitated state. The multidisciplinary team has developed a specific process to establish, review and refine structured programmes until the person emerges from the agitated state to RLACFS stage 6.
This paper will outline the theoretical basis and rationale for structured programmes and outline the team processes involved in establishing and reviewing them. Case examples will be presented to illustrate the usefulness and effectiveness of such programmes.